role of academic medical centers in the national quality ... · mindful variation and reduce...

Role of Academic Medical Centers in the National Quality Agenda

UC Health and the National Quality Agenda: An Opportunity

Dr. Peter Pronovost Director of the Armstrong Institute for Patient Safety and Quality, Senior Vice President of Patient Safety and Quality Johns Hopkins Medical

Toward eliminating all harm; the need for new narratives

Peter Pronovost, MD, PhD, FCCM

The Johns Hopkins University

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System

I will …

Three Narratives that hinder progress

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• Harm is inevitable rather than preventable • Safety is a local project rather than an integrated

operating management system

• Safety is based on the heroism of clinicians rather than the design of safe systems

New Narrative: Harm is preventable

Change in US CLABSI Rates Why did CLABSI Work at Policy Level? ► Reliable and valid measurement

system ► Evidence-based practices from

clinical and basic research ► Investment in implementation

(improvement) science* ► Local ownership (CUSP team)

and peer learning communities ► Align and synergize efforts of

many around a common goal and measure

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health

System 8

Pronovost; 15 years after to err is human: a success story to learn from; BMJQS 2015 *

What did this work at organizational level

Pronovost J Health Outcomes and Management 2017

What did this work at a team and individual level

Dixon-Woods; Explaining Michigan Milbank Quarterly

New Narrative: Safety is an integrated operating management system rather than a project

The Armstrong Institute

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• Purpose: To partner with patients their loved ones and others to end preventable harm, continuously improve patient outcomes and experience and eliminate waste

• Principles • I am humble curious and compassionate • I respect appreciate and help other • I am accountable to continuously improve myself, my organization

and my community

• Programs; advance science, build capacity, implement interventions, inform policy

High Reliability Organizations

Photo credit: U.S. Navy

Pursuit of excellent performance under complex and dynamic conditions

Weick & Sutcliffe 2015

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HRO Industries Created Operating Management Systems Unifying framework for structured assurance of safety, quality, reliability

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To assure customer satisfaction, organizations

must produce, and continually improve, safe, reliable

products that meet or exceed customer, statutory and

regulatory requirements.

Integrated approach for organizational learning and continuous improvement

JHM Operating Management System 5 Core Elements

The Way We Work Together


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Element 1 – Governance, Leadership and Accountability • Can you name the accountable quality leaders for your

entire delivery system from board to care delivery sites • Can you map the flow of quality measures from the

care delivery sites up to board • Do you have explicitly defined shared leadership

accountability processes • Do you have a fractal management structures in which

each higher level of the organization creates a structure in which each lower level has a voice providing horizontal links for learning and vertical for accountability

• Do you have a standard framework to organization quality work throughout your delivery system 16 © The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins

Health System

Change Progresses at the Speed of Trust

17 ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

Use the levers and adaptive leadership to strengthen the links

ResponsibilityRole Clarity

and Feedback

Shared Leadership Accountability

Capacity Time and Resources

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Weaver; J Healthcare Management

HEALTH CARE EQUITY

Framework for Organizing Quality and Safety Work

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LEAN

Analytics

Marketing and Communications

Learning and Development

PATIENT SAFETY

EXTERNAL REPORTING

PATIENT EXPERIENCE VALUE

Strategic Partnerships

Research

Infection Prevention

MEASURES Risky providers, units & systems WORK CUSP

Mindful organizing

Culture measurement improvement

Event reporting

Safety case

MEASURES Survival PSI/HAC HAI Rankings WORK PMO

Work teams

Robust Process Improvement

A3 Project management

MEASURES CAHPS Narratives Grievances WORK Common language

PFACs

Include patients

Patient and families education

Care coordination

Family involved in decision-making

MEASURES stratified by Race Ethnicity Primary language WORK Measure development

Element 2 – Systems Thinking, Risk Identification and Mitigation

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• Do you have mechanisms to identify and mitigate risky providers, units, systems, and management systems

• Do you have unit based improvement teams (CUSP)

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns

Hopkins Health System

Element 3 – Capacity and Infrastructure

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• Have you defined and ensured capabilities and capacity to eliminate harm, continuously improve outcomes and experience and eliminate waste among all staff, those who manage quality and those who lead quality

• Have you defined and ensured competencies to prevent the common causes of harm among all staff

• Have you created an enabling infrastructure to coordinate project managing, learning and development, analytics, improvement science, communications, and research


Element 4 – Transparency, Communication and Teamwork

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• Do leaders declare and communicate purpose, principles and goals

• Do leaders create a culture of respect, build trust and instill a hunger to learn and improve

• Do leaders ensure all staff are respected, have resources and are recognized

• Do leaders create a culture where all can speak out and up, addressing the “untouchables”

• Do you create structures and build trust c between upstream and down stream teams

• Do you implement huddles (daily management) at a unit, department, and organizational levels


Element 5 – Insight and Innovation • Have leaders created a culture to increase

mindful variation and reduce mindless variation

• Have leaders engaged clinicians in clinical communities

• Have leaders triangulated data and analytics to learn and improve

• Does the organization at all levels run experiments and learn, including from outside organizations


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Knowledge &

Understanding

Synthesized Information

Validated Data

Noise

Innovation

Clinical Communities Self-governing networks with representation from entire

health system Led by local physicians (1 academic lead, 1 community lead)

with interdisciplinary membership that includes patients and families

Set and communicate clear goals and measures related to purpose

Armstrong Institute provides vertical support for project management, peer learning, analytics, and robust process improvement

Work collaboratively on quality improvement projects, empowered to make changes

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Clinical Communities

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▪ Joint Replacement ▪ Blood Management ▪ Spine ▪ Surgery ▪ Cardiac Surgery ▪ ICUs ▪ Congestive Heart Failure ▪ Diabetes ▪ Palliative Care ▪ Cardiac Rhythm

Management

▪ Hospitalists (EQUIP) ▪ Stroke ▪ Craniotomy ▪ Psychiatry and

Behavioral Sciences ▪ Patient and Family

Centered Care ▪ Patient Centered

Care/Maternal Health ▪ Cleaning, Disinfection,

Sterilization ▪ Medication Safety

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Red Blood Cell Use in JHHS

Red Blood Cell Utilization Rate by Individual Hospitals

FY 2015

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Transfusion in Hip and Knee replacement across JHHS

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HIP Volumes JHBMC: 200 cases/year Suburban: 500 cases/year Sibley: 500 cases/year

KNEE Volumes JHBMC: 300 cases/year Suburban: 900 cases/year Sibley: 500 cases/year

HIP KNEE

~$2,000 per case reduction In variable direct cost at JHBMC

Supply Chain Initiatives

• Spine Vendor capping

initiative- $3.3 million

• ICU CVL kits Foley Kits Pharmaceuticals

• Blood

Management • $1.3 million

• Joint Cement- $150,000 Vendor capping

initiative- $1.5 million

• Surgery $780,000 savings by

reducing the number of vendors for sutures and endomechanicals

Hemostasis

• Cardiac Surgery Opportunity by

reducing Nitric oxide usage- $920,000

Spine Accomplishments to date: Development and implementation of ACDF

pathway- LOS

Current initiatives: Final review and implementation of Lumbar

Fusion Pathway Development of pathway for deformity

procedures Partnership with JHHC to develop a bundling

strategy

On Pathway Off Pathway

Ortho 1.63 2.71

Neuro 1.64 3.95

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Colorectal CUSP/ERAS Surgical Site Infection Rate

ACS-NSQIP data

Baseline 27%

Post-ERAS 6%

Colorectal Operating Room CUSP ERAS

Hospital Target 15%

Chart1

FY 2010

FY 2011

FY 2012

FY 2013

Q1/2 2014

Q3/4 2014

Series 1

0.27

0.17

0.2

0.16

0.2

0.06

Sheet1

Series 1

FY 201027%

FY 201117%

FY 201220%

FY 201316%

Q1/2 201420%

Q3/4 20146.00%

To update the chart, enter data into this table. The data is automatically saved in the chart.

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SSI Rates in JHH GYN ONC Colon Cases: 2013 - 2014

33%

0%

25%

11% 9%

33%

Interim Goal 2014 12%

IMPLEMENTATION OF SSI BUNDLE

Narrative 3: Safety is based on design of safe systems

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Hand Calculations

Constant False Alarms

Unreliable Systems

Devices don’t share data Low Productivity

ICU Current State

Potential of Productivity

Source: Kellerman, Health Affairs, 2013

Harms

Delirium

Acquired Physical Impairment

Ventilator associated infections and harms

DVT-PE

CLABSI

Loss of Respect and Dignity

Failure to provide care consistent with patient

goals

DELIRIUM

CAM ICU assessments

Automated screening

Modifiable factors

Non-pharmacologic interventions

Sedation management

Pain Scores

Family education

Acquired Physical Impairment

Early ambulation

Adjunctive physical therapy

Pharmacologic management

Prospective testing

Family engagement

Transition of care planning

Ventilator Harm

Daily sedation vacation (SAT)

Daily spontaneous breathing trials (SBT)

Automated ventilator management

Lung Protective Ventilation for ALI

Low Volume Ventilation if not ALI

DVT-PE

Initial VTE risk stratification for all ICU patients

Computerized clinical decision support (CDS) tool to aid ordering of best-practice VTE

prophylaxis

Ongoing risk re-stratification

Reminders when contraindications change to prompt addition of pharmacologic prophylaxis

Ultrasound screening of appropriate patients

Prevent missed prophylaxis doses

Optimal Mechanical Prophylaxis Use (Sequential Compression Device [SCD] and

compression stockings [TEDS])

VAP Head of Bed Elevation (HOB) ( ≥

30 degrees).

Spontaneous Awakening and Breathing Trials (SAT & SBT)

Oral Care

Oral Care with Chlorhexidine

Subglottic Suctioning ETTs

Loss of Respect and Dignity

Interpersonal communication

Scheduling

Education

Goals alignment

Access to care team

Inclusion

Continuity

Failure to provide care consistent with patient

goals Family meetings

Advanced directives

All teams meetings

Ethics engagement

Palliative Care

CLABSI

Hand washing

Chlorhexidine

Full Barrier Precautions

Avoid femoral site

Remove Unnecessary line

Use of checklist

Availability of cart

Harms to be eliminated – Associated Tasks

2/27/2017 39

Emerge

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health

System 40

Questions for Discussion

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• What narratives are you telling that are holding you back • Have you declared a goal of eliminating harms • Is quality a project or an integrated management system

• Does your quality governance structure function with the same rigor as finance

• Do you have trust building structures that support peer learning and accountability

• Do you have a common framework for organizing the work throughout your system

• Have you instilled a culture of respect, trust and learning • Would all your employees answer yes when asked if they are treated with

respect, have necessary resources, and are recognized • Do all employees feel free to speak up and out • Does all employees feel have a hunger to learn and improve.


I will …

New Narrative: Harm is preventable

Slides for Reference

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• The Board shall ensure that management creates a structure and reporting system such that the Board has oversight for quality and safety of care everywhere that care is delivered within the health system

• To accomplish this comprehensive oversight, management shall map the delivery system from the Board to the bedside

Element 1 – Governance, Leadership and Accountability


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• The Board shall ensure that a framework for reporting quality and safety of care mirrors the rigor and comprehensiveness of a consolidated financial statement



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• The Board shall define an accountability system for quality and safety when any part of the organization misses quality goals or has an unacceptable level of risk



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• Management shall seek to anticipate and prevent mishaps by standardizing work whenever possible

• Safety culture surveys, event reporting and ”near miss” data shall be continually utilized to inform and develop corrective and preventive actions

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns

Hopkins Health System 48

Risky Systems

Risky Provide

rs

Risky Units

• Risk identification and mitigation shall be informed by triangulated evidence such as indicators of risky providers, units and systems


• Management shall ensure that staff understand the upstream and downstream implications of their work, and partner effectively with colleagues in both directions

• Unit-based clinical teams shall be created to improve patient safety culture and provide frontline caregivers the tools and support to eliminate harm

© The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System 49

CUSP Growth

50

020406080

100120140160

Total CUSP Teams at JHM

Element 3 – Capacity and Infrastructure • Management shall create a fractal management

structure for quality in which management defines the delivery system structure and ensures that every higher level of the organization creates a forum in which every lower level helps co-create the quality approach


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• Management shall structure a learning model with quality and safety training targeted and tailored systematically for all staff including leadership

• Clinical staff shall demonstrate skills and competencies to prevent the common causes of preventable harm in their area



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• Leadership shall establish a Patient and Family Advisory Council with representatives on key quality and safety committees

• Management shall empower all staff to speak up and stop hazardous conditions to prevent harm and share wisdom to improve patient outcomes and experience

• Management shall address disruptive staff with no one “untouchable”

• Leadership shall enact a bundle of human resource practices to recruit, reward and retain staff that embrace the culture of safety and teamwork

JHBMC True North Room


• Senior leaders shall declare and communicate goals

• Managers empower staff to speak up and stop hazardous conditions to prevent harm and share wisdom to improve patient outcomes and experience

• Lean Daily Management strategies shall be employed to support peer learning and accountability

HCGH Observation Unit

Sibley Hospital CT

Element 5 – Insight and Innovation • Strategies shall be developed to systematically

promote the realization, preservation, availability and application of new knowledge

• Management shall create clinical communities to integrate knowledge, standardize practices, promote innovation, efficiency and value

• An integrated analytics capability shall be created to support improvement work and synthesize information from multiple sources to identify strengths and weaknesses


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Knowledge &

Understanding

Synthesized Information

Validated Data

Noise

Innovation

Examples of Habits for HRO

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• Habits to anticipate and prevent mishaps through standard work • Observe work; get ground truth daily • Shadow another role • Ask daily, how will this and next patient be harmed • Leaders ask how will operational and financial decisions introduce risks • Leaders ask will all employees say they are are treated with respect by

everyone, they have the resources and competencies they need and they are recognized

• Habits to recover from mishaps • Conduct daily rounds • Managers create structures to link up and down stream teams • Leaders create a culture of speaking up and speaking out • Leaders actively seek our new information especially bad news • Leaders address untouchables and disruptive behavior • All build in pause points in confusing situations • All use standard protocols for communicating (STICC

References; Patient Harm is Preventable not Inevitable

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1Pronovost et al. Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf 2016;25:396-399. 2Pronovost et al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM 2006;355;2725-2732. 3Bion et al. ‘Matching Michigan’: a 2-year stepped interventional programme to minimize central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013;22:110-123. 4Palomar et al. Impact of a national multimodel intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience. Crit Care Med 2013;41:2364-2372. 5Lipitz-Snyderman et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011;342:d219. 6Dixon-Woods et al. Explaining Michigan: Developing an ex post theory of a quality improvement program. Milbank Q 2011;89:167-205.

References; Safety is an operating management system

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Pronovost et al. The Armstrong Institute: An academic institute for patient safety and quality improvement, research, training, and practice. Acad Med 2015;90:1331-1339.

Pronovost et al. Sustaining reliability on accountability measures at The Johns Hopkins Hospital. Jt Comm J Qual Patient Saf 2016;42:51-60.

Pronovost et al. Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. Acad Med 2015;90:165-172.

Mathews et al. A model for the departmental quality management infrastructure within an academic health system. Acad Med 2016 Sep 6 epublication.

Pronovost et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf 2013;39:531-544.

Safety is based on design of safe systems

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Pronovost & Bo-Linn. Preventing patient harms through systems of care. JAMA 2012;308:769-770.

Pronovost et al. From heroism to safe design: leveraging technology. Anesthesiol 2014;120:526-529.

Romig et al. Developing a comprehensive model of intensive care unit processes: concept of operations. J Patient Saf 2015 Apr 23 epublication.

Mathews S & Pronovost. The need for systems integration in health care. JAMA 2011;305:934-935.

Role of Academic Medical Centers in the National Quality AgendaToward eliminating all harm; �the need for new narrativesI will …Slide Number 4Three Narratives that hinder progressNew Narrative: Harm is preventableSlide Number 7Change in US CLABSI RatesSlide Number 9What did this work at a team and individual levelNew Narrative: Safety is an integrated operating management system rather than a projectThe Armstrong InstituteHigh Reliability OrganizationsHRO Industries Created Operating Management Systems�Unifying framework for structured assurance of safety, quality, reliabilityJHM Operating�Management System�5 Core ElementsElement 1 – �Governance, Leadership and AccountabilityChange Progresses at the Speed of TrustShared Leadership AccountabilityFramework for Organizing Quality and Safety WorkElement 2 – Systems Thinking, Risk Identification and MitigationElement 3 – �Capacity and InfrastructureElement 4 – �Transparency, Communication and TeamworkElement 5 – �Insight and InnovationClinical Communities Clinical CommunitiesRed Blood Cell Use in JHHSRed Blood Cell Utilization Rate by Individual HospitalsTransfusion in Hip and Knee�replacement across JHHSSlide Number 29 Supply Chain InitiativesSpineColorectal CUSP/ERAS�Surgical Site Infection RateSSI Rates in JHH GYN ONC Colon Cases: 2013 - 2014Narrative 3: Safety is based on design of safe systemsICU Current StatePotential of ProductivityHarms to be eliminated – Associated TasksSlide Number 38Emerge Slide Number 40Questions for DiscussionI will …New Narrative: Harm is preventableSlides for ReferenceElement 1 – �Governance, Leadership and AccountabilityElement 1 – �Governance, Leadership and AccountabilityElement 1 – �Governance, Leadership and AccountabilityElement 2 – Systems Thinking, Risk Identification and MitigationElement 2 – Systems Thinking, Risk Identification and MitigationCUSP GrowthElement 3 – �Capacity and InfrastructureElement 4 – �Transparency, Communication and TeamworkJHBMC True North RoomElement 5 – �Insight and InnovationExamples of Habits for HROReferences; Patient Harm is Preventable not InevitableReferences; Safety is an operating management systemSafety is based on design of safe systems

role of academic medical centers in the national quality ... · mindful variation and reduce...

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